Provider Demographics
NPI:1104345842
Name:MARRIOTT, ERICA GAIL (FNP-C)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:GAIL
Last Name:MARRIOTT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:GAIL
Other - Last Name:LOVORN, HAYHURST BUCKNER MENDENHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1202 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:65793-3588
Mailing Address - Country:US
Mailing Address - Phone:417-469-1820
Mailing Address - Fax:
Practice Address - Street 1:1202 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:65793-3588
Practice Address - Country:US
Practice Address - Phone:417-469-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003015908163W00000X
MO2017035199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2003015908OtherMISSOURI STATE BOARD OF NURSING REGISTERED NURSE
F09171097OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICAN BOARD FAMILY NURSE PRACTITION